Africans living longer but spend those extra years in poor health

People are now living longer in sub-Saharan Africa than they did two decades ago, writes Charles Shey Wiysonge, director, Cochrane South Africa, in The Conversation. However, the data suggest that these people are living many years in poor health.

He writes: “This is an achievement, given that life expectancy in the region went down the drain from the 1990s to the mid-2000s as it choked under the devastating effects of the HIV epidemic.

“The question to ask is whether the additional years are spent in good or poor health. This question matters because how long people live affects the population’s state of health and leading causes of disability. Longevity means that these change over time which in turn has implications for policy, planning and provision of services.

“We used information from the Global Burden of Disease study to calculate healthy life expectancy in sub-Saharan Africa. Healthy life expectancy refers to the average number of years that a person at a given age can expect to live in good health, taking into account mortality and loss of functional health.

“The data suggest that people are living many years in poor health in the region. And our paper shows that there are large inequalities in healthy life expectancy and disease burden between – and within countries – in sub-Saharan Africa. This points to the fact that much more effort is needed to increase healthy life expectancy in the region.

“We found that the increase in healthy life expectancy in sub-Saharan Africa was smaller than the increase in overall life expectancy. This indicates that many years are lived in poor health in the region. In 2017, life expectancy at birth in sub-Saharan Africa was 63.9 years, but healthy life expectancy was only 55.2 years. This means that 13.6% of years of life in the region is spent in poor health.

“Life expectancy in 2017 varied by sub region, ranging from 62.4 years in Central Africa to 65 years in Southern Africa. However, in Central Africa 14.4% and in Southern Africa 13.8% of these years are estimated to be spent in poor health, respectively. The proportion of years of life spent in poor health varied between countries, ranging from 11.9% in Djibouti to 14.8% in Botswana.

“While women live longer than men, many of these extra years are lived in poor health. The life expectancy at birth for women in sub-Saharan Africa in 2017 was 66.2 years, but healthy life expectancy was only 56.8 years. Thus, women spend 14.2% of their years in poor health. For men, life expectancy was 61.7 years and healthy life expectancy was 53.7 years. Thus, men in sub-Saharan African spend 13% of their lives in poor health.

“The average healthy life expectancy at birth in sub-Saharan Africa increased by 9.1 years, from 46.1 years in 1990 to 55.2 years in 2017. The increase in health life expectancy at birth varied from 0.9 years in Southern Africa to 12.4 years in Eastern Africa.

“Even larger variations in healthy life expectancy than these were observed between countries, ranging from a decrease of 4.9 years in Lesotho (51.9 years in 1990 to 47 years in 2017) to an increase of 23.7 years in Eritrea (30.7 years in 1990 to 54.4 years in 2017). In most countries, the increase in healthy life expectancy was smaller than the increase in overall life expectancy, indicating more years lived in poor health.

“We calculated a measure known as disability-adjusted life-years, which captures both early death and ill health. In 2017, the leading causes of disability-adjusted life-years in sub-Saharan Africa for all ages and both sexes combined were neonatal disorders, pneumonia, HIV/Aids, malaria, and diarrhoea.

“However, we observed various dramatic changes in causes of early death and disability between 1990 and 2017. Measles decreased from a ranking of 5th to 20th, heart attacks increased from 16th to 11th, stroke from 12th to 10th, and diabetes from 27th to 14th. We are thus witnessing gradual shift from communicable to non-communicable causes of disease burden.

“There was wide variation between countries in the causes of early death and disability.
In Eritrea, the top causes of early death and disability were neonatal disorders, diarrhoea, tuberculosis, pneumonia, and congenital defects. The most dramatic changes were with conflict and terror (1st in 1990 to 14th in 2017), measles (7th to 74th), tetanus (9th to 82nd), heart attacks (17th to 11th), stroke (12th to 10th), and diabetes (22nd to 15th).

“In the Central African Republic, the top causes of early death and disability were diarrhoea, neonatal disorders, pneumonia, HIV/Aids, and tuberculosis. The main changes were with conflict and terror (164th to 9th), measles (7th to 20th), heart attacks (14th to 11th), and diabetes (21st to 16th).

“In South Africa, the top causes of early death and disability were HIV/Aids, neonatal disorders, pneumonia, interpersonal violence, and diabetes. The most dramatic changes occurred with HIV/Aids (53rd to first), measles (12th to 55th), diarrhoea (2nd to 8th), and diabetes (from 13th to 5th).

“In the Gambia, the top causes of early death and disability were neonatal disorders, pneumonia, HIV/Aids, diarrhoea, and sickle cell disease. There were substantial changes in rankings for HIV/Aids (61st in 1990 to 3rd in 2017), malaria (4th to 25th), measles (9th to 70th), heart attacks (13th to 6th), stroke (14th to 9th), and diabetes (28th to 18th).

“Since 1990, we have seen exceptional progress in sub-Saharan Africa in reducing the burden of communicable diseases, especially measles, tetanus and other vaccine-preventable diseases. However, early death and disability due to these causes remain unnecessarily high in many countries. Immunisation efforts have been helpful, but progress in coverage has slowed in the past decade. Close to 20m children worldwide, most of them in sub-Saharan Africa, didn’t receive vaccines against these deadly diseases in 2017. Conflict, inadequate investment in national immunisation programmes, and vaccine stock outs were among the reasons for the stalled progress in immunisation coverage.

“Our report shows that there is an unfinished agenda of controlling communicable diseases – compounded by an increase in non-communicable diseases – in sub-Saharan Africa. The continued burden of disabling conditions has serious implications for health systems and health-related expenditures in the region.”

Summary Background: The Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017) includes a comprehensive assessment of incidence, prevalence, and years lived with disability (YLDs) for 354 causes in 195 countries and territories from 1990 to 2017. Previous GBD studies have shown how the decline of mortality rates from 1990 to 2016 has led to an increase in life expectancy, an ageing global population, and an expansion of the non-fatal burden of disease and injury. These studies have also shown how a substantial portion of the world’s population experiences non-fatal health loss with considerable heterogeneity among different causes, locations, ages, and sexes. Ongoing objectives of the GBD study include increasing the level of estimation detail, improving analytical strategies, and increasing the amount of high-quality data. Methods: We estimated incidence and prevalence for 354 diseases and injuries and 3484 sequelae. We used an updated and extensive body of literature studies, survey data, surveillance data, inpatient admission records, outpatient visit records, and health insurance claims, and additionally used results from cause of death models to inform estimates using a total of 68 781 data sources. Newly available clinical data from India, Iran, Japan, Jordan, Nepal, China, Brazil, Norway, and Italy were incorporated, as well as updated claims data from the USA and new claims data from Taiwan (province of China) and Singapore. We used DisMod-MR 2.1, a Bayesian meta-regression tool, as the main method of estimation, ensuring consistency between rates of incidence, prevalence, remission, and cause of death for each condition. YLDs were estimated as the product of a prevalence estimate and a disability weight for health states of each mutually exclusive sequela, adjusted for comorbidity. We updated the Socio-demographic Index (SDI), a summary development indicator of income per capita, years of schooling, and total fertility rate. Additionally, we calculated differences between male and female YLDs to identify divergent trends across sexes. GBD 2017 complies with the Guidelines for Accurate and Transparent Health Estimates Reporting. Findings: Globally, for females, the causes with the greatest age-standardised prevalence were oral disorders, headache disorders, and haemoglobinopathies and haemolytic anaemias in both 1990 and 2017. For males, the causes with the greatest age-standardised prevalence were oral disorders, headache disorders, and tuberculosis including latent tuberculosis infection in both 1990 and 2017. In terms of YLDs, low back pain, headache disorders, and dietary iron deficiency were the leading Level 3 causes of YLD counts in 1990, whereas low back pain, headache disorders, and depressive disorders were the leading causes in 2017 for both sexes combined. All-cause age-standardised YLD rates decreased by 3·9% (95% uncertainty interval [UI] 3·1–4·6) from 1990 to 2017; however, the all-age YLD rate increased by 7·2% (6·0–8·4) while the total sum of global YLDs increased from 562 million (421–723) to 853 million (642–1100). The increases for males and females were similar, with increases in all-age YLD rates of 7·9% (6·6–9·2) for males and 6·5% (5·4–7·7) for females. We found significant differences between males and females in terms of age-standardised prevalence estimates for multiple causes. The causes with the greatest relative differences between sexes in 2017 included substance use disorders (3018 cases [95% UI 2782–3252] per 100 000 in males vs s1400 [1279–1524] per 100 000 in females), transport injuries (3322 [3082–3583] vs 2336 [2154–2535]), and self-harm and interpersonal violence (3265 [2943–3630] vs 5643 [5057–6302]). Interpretation: Global all-cause age-standardised YLD rates have improved only slightly over a period spanning nearly three decades. However, the magnitude of the non-fatal disease burden has expanded globally, with increasing numbers of people who have a wide spectrum of conditions. A subset of conditions has remained globally pervasive since 1990, whereas other conditions have displayed more dynamic trends, with different ages, sexes, and geographies across the globe experiencing varying burdens and trends of health loss. This study emphasises how global improvements in premature mortality for select conditions have led to older populations with complex and potentially expensive diseases, yet also highlights global achievements in certain domains of disease and injury.

With an average life expectancy of 63.6 years, most South African babies born this year probably won’t live to see the next century. But Business Insider reports that according to data from the World Health Organisation, children in more than twenty other countries will most likely have exactly that privilege.

The average Japanese new-born, given that country’s average life expectancy of longer than 84 years, could easily see in the year 2100. Other countries who have a longer life expectancy than the necessary 81 years include Singapore, France, Germany, Greece and Australia.

The report says while the average life expectancy in South Africa is longer than Nigeria (55.2 years), other Africans live longer. The Congo (64.3), Malawi (64.2), Kenya (66.7) and Rwanda (68.0) all have greater average lifespans. In India, life expectancy is more than five years longer than in South Africa, while in Brazil the average lifespan is 75.1 years.

According to the World Health Organisation’s World Health Statistics 2018 report, South Africa has one of the highest rates of universal health coverage on the continent, with 97% of births attended by skilled health personnel. But the WHO statistics show that TB, HIV, and other diseases are taking a massive toll on the country’s health.

The report says while the South African homicide rate is out of whack on the continent, it’s in line with some homicide mortality rates in South America.

The report says despite all these challenges, statistics show that the South African suicide mortality rate – 11.6 out of 100,000 people – is much lower than in many rich countries.

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